"This growth in the use of healthcare services 31 to 365 days after an acute MI challenges efforts to control costs," they wrote. "A potential approach is to extend bundled or episode-based reimbursements to periods beyond 30 days."

The findings come against a 5.9% annual growth in Medicare expenditures per beneficiary over the past decade, despite stagnant or even regressive reimbursement rates, the group noted.

Nor was the increased Medicare spending from changes in technology utilization during the initial hospitalization, they explained.

"Instead, expenditures 31 to 365 days after the index admission rose by 28.0% because of increased use of home health agencies, hospices, durable medical equipment, skilled nursing facilities, and inpatient services," they wrote.

An accompanying invited commentary pointed out that while much of the focus has been on hospital care in slowing the growth in healthcare costs, "we may not be looking for savings in the right place."

Ashish K. Jha, MD, MPH, of Harvard School of Public Health, called the findings a wake-up call to federal policymakers. "It is likely that modest changes can be made to existing programs and activities, such as extending bundled payments, redoubling efforts to encourage accountable care organizations, and measuring the value of services following post-acute care," he wrote.

"Measuring value may be hard work, because our understanding of the appropriateness and value of services following early post-acute care is so rudimentary. But we have to do it -- because, as Willie Sutton would say, that's where the money is."

The study included 317,403 fee-for-service Medicare beneficiaries hospitalized for an acute MI, taken from a random 20% sample from 1998 through 1999 and from a 100% sample for 2008.

Over that period, acute MI incidence dropped 19% and shifted to an older, sicker patient profile with more comorbidities.

Bypass surgery gave way to percutaneous coronary intervention and length of hospitalization shrank from 6 days to 5, but there was a compensatory 75% increase in skilled nursing facility use in the first 30 days.

Skilled nursing facility spending, together with inpatient charges, accounted for the greatest absolute change in cost, a total of $3,033 per patient in the first year after a heart attack, and nearly half of the overall cost increase.

Readmissions didn't change much, but their cost climbed 9.8%.

Notably, physician expenditures during the initial hospitalization fell 1% over the study period, though physician expenditures after the first 30 days climbed 22%, primarily due to a 44% increase in outpatient physician spending.

Altogether, spending per beneficiary in the first 30 days rose 7.5% from 1998 to 2008 ($1,560 per patient), while spending through the rest of the first year post-MI increased by 28% ($4,535).

The problem is that there's little evidence that patients benefited more from the extra expenditure, Jha argued.

"Although services in the late period of care explained around three-fourths of the cost growth, they accounted for only approximately one-fourth of the gains in mortality," he wrote. "It is debatable whether the use of these additional services improved the quality of life of Medicare beneficiaries -- but the study by Likosky et al. provides little evidence that it did."

Limitations of the study included the possibility of unmeasured confounding, inability to tie specific medical treatments to mortality declines over the study period, and lack of data on Medicare Advantage patients, as well as on fee-for-service patients' out-of-pocket expenditures or supplemental insurance payments.

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